Nokea
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?
- A. Hold breaths about 3 to 5 seconds before exhaling.'
- B. Exhale slowly through pursed lips.'
- C. Position the mouthpiece 2.5 cm (1 in) from the mouth.'
- D. Place hands on the upper abdomen during inhalation.'
Correct Answer: A
Rationale: Correct Answer: A. Hold breaths about 3 to 5 seconds before exhaling.
Rationale: Holding the breath for a few seconds after inhaling with an incentive spirometer helps to fully expand the lungs and improve lung function. This technique prevents air from escaping too quickly and allows for optimal oxygen absorption. It also encourages deep breathing, which is essential for clearing the airways and improving overall lung capacity.
Summary of other choices:
B: Exhaling slowly through pursed lips is a technique used in pursed lip breathing, not with an incentive spirometer.
C: The position of the mouthpiece is important for comfort but not directly related to using the incentive spirometer.
D: Placing hands on the upper abdomen during inhalation is not a recommended technique for using an incentive spirometer.
You may also like to solve these questions
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
- A. Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
- B. Decrease in heart rate to 120 bpm
- C. Rapid
- D. shallow respirations
- E. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg. Cushing's triad is a set of three classic signs indicating increased intracranial pressure (ICP). The triad includes hypertension (widening pulse pressure), bradycardia, and irregular respirations. In this case, an increase in blood pressure is consistent with the hypertension component of Cushing's triad. This occurs due to the body's compensatory mechanism to maintain perfusion to the brain in response to increased ICP. Choices B, C, D, and E do not align with the classic signs of Cushing's triad. Bradycardia, not a decrease in heart rate, is typically seen in Cushing's triad. Rapid and shallow respirations are not part of the triad. Hypotension is not a characteristic finding in Cushing's triad.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an accumulation of carbon dioxide in the bloodstream due to inadequate ventilation. This leads to increased levels of carbonic acid, causing the blood pH to decrease. The nurse should identify this mechanism as responsible for the acid-base imbalance.
Loss of bicarbonate (B) would lead to metabolic acidosis, not respiratory acidosis. Excessive vomiting (C) would result in metabolic alkalosis. Hyperventilation (D) would actually help correct respiratory acidosis by blowing off excess carbon dioxide.
A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?
- A. Projectile vomiting
- B. Decorticate posturing
- C. Restlessness
- D. Papilledema
Correct Answer: C
Rationale: The correct answer is C: Restlessness. In early stages of increased ICP, the brain tries to compensate by increasing blood flow to maintain perfusion, leading to restlessness. Projectile vomiting (A) is a late sign due to pressure on the vomiting center. Decorticate posturing (B) and papilledema (D) are late signs of increased ICP.
A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching?
- A. Consume a diet that is high in calories.
- B. Limit fluid intake to prevent mucus production.
- C. Engage in strenuous exercise daily.
- D. Reduce carbohydrate intake to prevent fatigue.
Correct Answer: A
Rationale: The correct answer is A: Consume a diet that is high in calories. Patients with COPD often have increased energy needs due to the increased work of breathing. Providing a high-calorie diet helps maintain energy levels and prevent weight loss. Choice B is incorrect because adequate hydration is crucial to help thin mucus and make it easier to clear from the airways. Choice C is incorrect as strenuous exercise can exacerbate COPD symptoms; moderate exercise is recommended. Choice D is incorrect because carbohydrates are an essential energy source and reducing intake can lead to increased fatigue in COPD patients.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure?
- A. Crackles in the lungs
- B. Increased abdominal girth
- C. Pink frothy sputum
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Increased abdominal girth. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, causing blood to back up into the systemic circulation. This leads to fluid retention, particularly in the lower extremities and abdomen, resulting in increased abdominal girth. Crackles in the lungs (A) are indicative of left-sided heart failure due to pulmonary congestion. Pink frothy sputum (C) is associated with pulmonary edema, a sign of left-sided heart failure. Hypertension (D) is not typically associated with right-sided heart failure, as it is more commonly seen in conditions like systemic hypertension.